Tuberculous Gumma Or Metastatic Tuberculous Abscess As Initial Diagnosis of Tuberculosis in an Immunocompetent Patient: an Unusual Presentation

Rev Esp Sanid Penit 2014; 16: 59-62 39 A Marco, R Solé, E Raguer, M Aranda. Tuberculous gumma or metastatic tuberculous abscess as initial diagnosis of tuberculosis in an immunocompetent patient: an unusual presentation

Revisions of Clinical Cases: Tuberculous gumma or metastatic tuberculous abscess as initial diagnosis of tuberculosis in an immunocompetent patient: an unusual presentation

A Marco, R Solé1, E Raguer1, M Aranda1

Servicios Sanitarios del Centro Penitenciario de Hombres de Barcelona (CPHB) y Servicio de Medicina Interna del Hospital Consorci Sanitari de Terrasa (HCST)1.

Abstract

Background and Objectives: Tuberculous cold abscesses or gumma are an unusual form of tuberculosis. We report a case of gumma as initial diagnosis of disseminated tuberculosis. Method: This case was studied in 2012 in Barcelona (Spain). Source data was compiled from the electronic clinical records, hospital reports and additional diagnostic testing. Results: Immunocompetent inmate, born in Cape Verde, living in Spain since the age of four. Positive tuberculin skin test. Initial examination without interest, but a palpable mass in lower back. Fine needle aspiration of the abscess was positive (PCR and Lowenstein) for M. tuberculosis. Computed tomography showed lung cavitary nodes in apical part and lung upper right side. After respiratory isolation, antituberculous therapy and an excellent evolution, the patient was discharged from hospital with disseminated tuberculosis diagnosis. Discussion: It is advisable to monitor the injuries since, although rare, it may be secondary to Mycobacterium tuberculosis infection, mainly in inmuno-compromised populations and in immigrants coming from hyper-endemic tuberculosis areas. Keywords: Prisons; Tuberculosis, cutaneous; Spain; Diagnosis, Differential; Endemic Diseases; Abscess; HIV.

Text received: 24-10-2013 Text accepted: 17-01-2014

1. INTRODUCTION ous disease account for less than 0.5% of all cases in developed countries and its prevalence is even lower In 2010 there were almost 9 million new cases of if we exclude tuberculosis due to BCG and tubercu- tuberculosis (TB) worldwide which were responsible lids. The main objective of this report is to present the for 350,000 deaths among HIV patients and for 1.1 case of a young man without congenital or acquired million deaths among non HIV patients. In spite of immunodeficiency who was diagnosed with miliary these figures the absolute number of TB cases has fol- tuberculosis from a soft tissue abscess located in the lowed a decreasing trend ever since 2006 instead of lumbar region. the rise which had been predicted1. The main clinical presentation is pulmonary tuberculosis although bacillus disseminated during the initial infection may 2. METHODS be hosted in any tissue. Extrapulmonary forms repre- sent 10 to 20% of TB cases among immunocompetent Clinical case studied and diagnosed between patients but this presentation increases in immuno- March and May 2012 by the medical services of the compromised hosts. The main extrapulmonary sites Male Prison of Barcelona (Centro Penitenciario de of infection are lymph nodes, the osteoarticular sys- Hombres de Barcelona CPHB) and the department tem, the genitourinary system, the meninges and the of internal medicine of the Hospital Consorci Sanitari brain. Other clinical presentations such as the cutane- in Terrassa (HCST). For the description of the casa, — 59 — 40 Rev Esp Sanid Penit 2014; 16: 59-62 A Marco, R Solé, E Raguer, M Aranda. Tuberculous gumma or metastatic tuberculous abscess as initial diagnosis of tuberculosis in an immunocompetent patient: an unusual presentation data was collected from the patient’s clinical record, sediment was normal. Thoracic x rays revealed a right from the hospital’s record (both emergency and pro- loculated pleural effusion, superior-anterior pleural grammed stay records) and from complementary tests thickening, medial mediastinal widening with paratra- conducted. cheal subcarinal and right parahilar occupation. An ill defined approximately 4 cm wide mass was also identified in the right upper lobe (RUL) which contacted 3. RESULTS with the pleura, together with right costophrenic angle blunting. CT of the chest and abdomen showed 35 year old male, natural from Cape Verde who a right apical cavitated nodule (1.8 x 1.6 cm) in the has lived in Spain ever since he was 4 years old. He pulmonary parenchyma, with adjacent micronodules, is currently imprisoned in Barcelona. He has been a 6mm wide nodule in the RUL and subsegmental smoking 10 cigarettes per day until 6 months ago and atelectasis in the middle lobe (ML), nodular thick- he occasionally smokes marihuana. He doesn’t report ening of the right apical pleura and affected medias- any other toxic habits. He has a history of multi- tinal pleura with an important left pleural effusion. ple fractures, some of which required surgery, after Furthermore, hypodense collections in intercostals falling from a fourth floor 16 months ago. In 2008: muscles, in the right adductor muscle and in right tuberculin intradermal reaction (IDR) of 25 mm. (5.8x3x2.5 cm) and left (4.4x3.2x1.6 and 1.9x1.5 cm) approximately one month and a half ago he initiated a paravertebral muscles were identified. Thoracentesis clinical picture of lumbar pain, dysthermic sensation, of the left hemithorax was conducted and the follow- shivering, dysuria, muscle cramps and paresthesia. ing was revealed: 40 cc of yellowish liquid (increased He received treatment based on anti-inflammatory ADA 2.2 ukat/L and negative cytology for malignant drugs and norfloxacin, with no improvement. He was cells). The aspiration puncture of the left lumbar lump then transferred to the emergency department of the revealed 10 cc of purulent liquid positive for M.tu- reference hospital. Blood tests showed the following berculosis by means of PCR testing and culture in results: CRP 17.7 mg/dl, normal leukocyte levels with the Löwenstein medium. The determination of lym- relative neutrophilia and leukopenia, thrombocytosis phocytic subpopulations (CD3, CD4, CD4 and coef- (448000/mcl), PT 65% and fibrinogen 9g/l. Abdom- ficients) revealed no alterations. Antibiogram tests inal and lumbar radiologic studies showed no patho- showed that the strain was sensitive to all the anti-TB logic results. Ultrasound examination of the kidneys, drugs. Sputum smear microscopy could not be con- bladder and prostate was then conducted to rule out ducted as the patient was not expectorating. A 4-drug dilatation of the excretory system. Lithiasis was also regimen together with respiratory isolation was ini- ruled out. A small unspecific 1.2 cm wide nodule was tiated. After the fever had disappeared together with identified in the middle prostate lobe which should be the lumbar pain and his general situation improved monitored in the future. A urine culture was ordered after the reduction of the left pleural effusion the before the possibility of urinary tract infection and patient was discharged and diagnosed with military the patient returned to the prison under treatment TB (pleural, pulmonary and muscle abscesses). The with cefixime 400 mg/24 h for 3 weeks, pending the surgery department managed the lumbar lump by results of the culture and the eventual adjustment of means of repeated aspiration punctures (See Figure 2). treatment according to the results of the antibiogram. A few days later, the results were informed to be negative by phone and an ultrasound conducted 4. DISCUSSION in prison showed minimum right effusion. Since the clinical manifestations persisted and the patient had Tuberculous abscesses are a relatively common eventually presented with constitutional symptoms complication of TB spondylitis 2, 3 and in such cases (weight loss, fatigue, anorexia and fever of 37.5 to 30ª, the psoas or paravertebral muscles may become mostly in the evening) he was admitted to the HCST affected, even years after the diagnosis has been made to continue the study. 4. Although it is a rare condition, tuberculous abscesses Upon hospital admission the patient had fever have also been described months after BCG vacci- (39ª). The physical examination was unspecific except nation 5. Nevertheless, cold abscesses or gumma are for the existence of a 5cm wide soft tissue lump on the actually a consequence of the metastatic spread, via the lumbar region (see Figure 1). Tumor markers, sero- blood, of latent mycobacteria which form abscesses logic testing for syphilis, hepatitis B and C and HIV most frequently in the limbs or the trunk usually spar- as well as blood culture tests were all negative. Urine ing deeper tissues. This is probably the physiopatho- — 60 — Rev Esp Sanid Penit 2014; 16: 59-62 41 A Marco, R Solé, E Raguer, M Aranda. Tuberculous gumma or metastatic tuberculous abscess as initial diagnosis of tuberculosis in an immunocompetent patient: an unusual presentation

logical mechanism that this patient suffered. There are few cases of tuberculous gumma in the literature and although they are more usually found in countries with high endemicity of TB 6, 7 they have also been described in other countries such as Japan 8 or the United States 9. Nevertheless, throughout recent years this presentation has experienced an increase mostly associated to immunocompromised patients10, mostly those infected by HIV 11. It has also been suggested that such presentations may be more frequent among the imprisoned population12, especially in prisons-like ours- where over 61% of those hosted are immigrants, coming from countries where TB is highly endemic with a prevalence of over 40% 13. To conclude we must remember that our patient actually arrived in Spain when he was only 4 years old. Therefore he could have become infected in Cape Verde- where the incidence rate of TB is 147 cases per every 100,000 people: five times higher than in Spain- or later in our country. It is also highly probable that he had been vaccinated with BCG14. We must also consider that in 2008 his LTBI was not treated and although there was no absolute indication at the time, the size of the intradermal reaction together with the fact that he was imprisoned both recommend the ini- tiation of LTBI treatment after ruling out the exis- Figure 1. Soft tissue abscess on the lumbar region. Lateral image. tence of active TB. Finally, this case suggests that lesions which are rare yet potentially involved with the infection by M.tuberculosis need to be closely monitored, especially in immunocompromised patients and immigrants from countries with a high endemicity of TB.

CORRESPONDENCE

Dr. Andrés Marco Servicios Médicos del Centro Penitenciario de Hombres de Barcelona. C/Entenza 155. Barcelona 08029. [email protected]

BIBLIOGRAPHICAL REFERENCES

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